Gross motor delays may be indicated by difficulties with jumping, hopping, balancing, skipping, or running.

A coordination disorder may be indicated by clumsiness, awkwardness of movement, and completing motor tasks by more difficult means than necessary. Children with coordination delays are often hesitant to attempt new tasks.

Not all children with learning, developmental, or behavioral problems have an underlying sensory integration disorder. There are certain indicators, however, that can signal that a disorder may be present. The following are a few of the possible signs.

1. Overly sensitive to touch, movement, signs, or sounds.
2. Under-reactive to sensory stimulation
3. Activity level that is unusually high or low
4. Coordination problems
5. Delays in speech, language, motor skills, or academic achievement
6. Poor organization of behavior
7. Poor self-concept

Typically, a child with a sensory integration disorder will show more than one of the above signs and may also be easily distracted, have social and emotional difficulties, be impulsive and lacking in self-control, have an inability to unwind or calm themselves, and difficulty with transitions between situations.

Feeding issues can include inadequate intake, food refusal, being selective about the type or texture of food, expelling or packing/pocketing food, oral motor weakness, gagging, biting of tongue or cheeks while eating, and difficulty using utensils.

Oral motor challenges may be indicated by difficulty chewing, sucking, blowing, and/or making certain speech sounds. Children are often unaware of food on their faces, have trouble keeping food in their mouths, or moving food around their mouths. The child may present with low muscle tone in the face (“long” or “droopy”), a “flat affect” look, open-mouth breathing, or excessive drooling.

Fine motor challenges may be indicated by difficulty with writing, self-feeding, self-dressing (buttons, zippers, snaps, tying), using utensils, and other hand skills.

• Doesn’t smile or interact with others (birth-3 months)

• Doesn’t babble (4-7 months)

• Makes few sounds (7-12 months)

• Does not use gestures such as waving and pointing (7-12 months)

• Doesn’t understand what others say (7 months-2 years)

• Says only a few words (12-18 months)

• Doesn’t put words together to make sentences (1 ½-3 years)

• Has trouble playing and talking with other children (2-3 years)

• Has problems with early reading and writing skills – for example, may not show an interest in books or drawing (2 ½-3 years)

Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits (abnormal reflexes, abnormal tone). CAS may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder. The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.

The following are symptoms of CAS:

• Limited or little babbling as an infant (void of many consonants). First words may not appear at all, pointing and “grunting” may be all that is heard.

• The child is able to open and close mouth, lick lips, protrude, retract and lateralize tongue while eating, but may not be able to when directed to do so.

• First word approximations occurring beyond the age of 18 months, without developing into understandable simple vocabulary words by age two.

• Continuous grunting and pointing beyond age two.

• Lack of a significant consonant repertoire: child may only use /b, m, p, t, d, h/

• All phonemes (consonants and vowels) may be imitated well in isolation, but any attempts to combine phonemes are unsuccessful.

• Prosody is unusual, there is equal stress or lengthy pauses between or within syllables or words, and sometimes a monotone quality.

• Speech may change or disintegrate with many repetitions.

• Words may be simplified by deleting consonants or vowels, and/or replacing difficult phonemes (consonants and vowels) with easier ones.

• Single words may be articulated well, but attempts at further sentence length become unintelligible.

• Receptive language (comprehension) appears to be better than attempts at expressive language (verbal output).

• One syllable or word is favored and used to convey all or many words beyond age two.

• The child speaks mostly in vowels.

• Verbal perseveration: getting “stuck” on a previously uttered word, or bringing oral motor elements from a previous word into the next word uttered.

• Oral groping may occur when attempting oral motor movements or consonant/vowel production.

• Struggle behavior may occur when attempting to imitate or to speak (without dysfluency or stuttering).

• Deletions or replacements of consonants, vowels or syllables may occur at the end of a word, phrase or connected word levels.

• Vowel distortions or replacements occur which are not due to oral motor weakness.

• The ability to blurt out clear whole words, phrases or sentences may occur though there is difficulty imitating these same words “on command” or upon imitation.

• Difficulty with maintaining clarity with extended word length or complexity.

• Many phonological processes are employed to simplify motor speech output.

• Late talking with above characteristics or errors may be present.

• Other fine motor challenges may be present.

• Echolalic utterances (the automatic repetition of words, phrases or sentences often without comprehension) might be perfectly articulated but novel attempts at words or combinations might be more effortful.

The following articulation errors are typical of preschoolers and are usually not cause for concern. If they persist past age five, an evaluation is necessary.Frontal and lateral lisps

• Weak articulation of /r/

• Substituting /j/ (the “y” sound) for /l/
• Difficulty with blends /r, l, s/ (brake, clown, slow)

Dysarthria (flaccid) is a speech disorder caused by dysfunctional or damaged innervation to the speech musculature (tongue, lips, soft palate, facial muscles, larynx).  Generally, oral musculature is weak.  Some children may have a functional dysarthria, due to inappropriate carriage of the tongue at rest.

The following are signs of dysarthria:

• Marked difficulties with strength, speech and accuracy of articulatory movement.

• Imprecise or weakly targeted consonants.

• Imprecise or weakly targeted vowels, especially those which involve spreading intrinsic tongue muscles, such as /i/, /ai/, /ei/, oi/.

• Weak vocal quality (lack of respiratory support).

• Hypo or hypernasality.

• Weak articulatory contacts.

• Rapid or slow speaking rate.

• Speech clarity disintegrates with lengthy utterances (this may be due to lack of breath support or muscle fatigue and may resemble apraxia of speech).

• Weak targets, especially for / r, s, l / and vowels.

• Generally weak, mushy, garbled, imprecise speech.

Many children with apraxia of speech have an accompanying oral-motor weakness. Usually, working on the apraxia inadvertently helps to strengthen weak articulatory contacts.

Severe dysarthria can be such a significant obstacle to motor-speech skill development in that the average listener may not be able to decode their speech. Children with severe dysarthria will require an augmentative communication system.

Children with expressive language disorder have difficulty with verbal expression (putting words together to formulate thoughts).

The following are symptoms of expressive language disorder:

• Word retrieval difficulties.

• Difficulty naming objects or “talking in circles” around subjects with lack of the appropriate vocabulary.

• Dysnomia (misnaming items).

• Difficulty acquiring syntax (the rules of grammar).

• Difficulties with morphology (changes in verb tense).

• Difficulty with semantics (word meaning).

Receptive language disorders include central auditory processing disorders (CAPD), aphasia, comprehension deficit, “delayed language,” and “delayed speech.” Receptive language disorders also refer to difficulties in the ability to attend to, process, comprehend, retain, or integrate spoken language.

The following are symptoms of a receptive language disorder:

• Echolalia (repeating back words or phrases either immediately or at a later time).

• Inability to follow directions (following of routine, repetitive directions may be OK).

• Inappropriate, off-target responses to “wh” questions.

• Re-auditorization (repeating back a question first and then responding to it).

• Difficulty responding appropriately to yes/no questions, either/or questions, who/what/where questions, and when/why/how questions.

• Not attending to spoken language

• High activity level and not attending to spoken language

• Jargon (sounds like unintelligible speech)

• Using memorized phrases and sentences.

Please note: Children with autism spectrum disorders often have difficulty decoding spoken language and may tend to memorize rather than have a true understanding of novel language.

Social pragmatic language disorder may also be known as semantic/pragmatic language disorder, nonverbal learning disability (NLD), or even autism/Asperger's syndrome.

The following are symptoms of social pragmatic language disorder:

• Excessive questioning.

• Lack of eye contact.

• Aggressive language.

• Excessive talk about specific subjects in too much detail

• Only talking about him/herself.

• Disinterested in other children.

• Unable to engage in conversational exchange.

• Literal/concrete understanding of language.

• Unable to answer open-ended questions such as “what happened?”

• Difficulty with abstract language such as verbal problem solving (why, when, how do you know?), double meanings, innuendos, and jokes.

• Difficulty taking the listener’s perspective.

• Difficulty reading or interpreting body language, facial expressions.

• Unable to express feelings.

Unintelligible speech is a descriptive term used subjectively by the listener.  It can be due to a few minor consonant or vowel errors, oral-structural differences, oral-motor weakness, dysarthria or apraxia of speech.

However, another casual factor to unintelligible speech, which even many professionals miss, is that of the faulty perception of language.  Children who have difficulty processing and comprehending spoken language, particularly children who exhibit autism spectrum disorders, may exhibit jargon (sometime called “gibberish,” or unintelligible speech).

It is important to uncover whether a child has an unusual capacity to memorize dialogue, which doesn’t necessarily hold any meaning for them and are reiterating it the way they perceive it, without attaching meaning.  In this case, the more emphasis there is upon improving processing and comprehension skills, the more improvement will be seen in increased intelligibility.  Whereas, unintelligible speech rooted in the fine-motor coordination aspect of talking would require motor-speech or verbal motor work.

Children may have both perceptual and motor-speech difficulties.  If there are any questions regarding whether the child comprehends spoken language, attention should be given to comprehension and not necessarily motor-speech output.

• Limited repertoire of vowels; less differentiation between vowel productions; and vowel errors, especially distortions.
• Variability of errors.
• Unusual, idiosyncratic error patterns (sometimes defying transcription).
• Errors increase with length or complexity of utterances, such as in multi-syllabic or phonetically challenging words.
• Depending on level of severity, a child may be able to produce accurately the target utterance in one context but is unable to produce the same target accurately in a different context.
• More difficulty with volitional, self-initiated utterances as compared to over-learned, automatic, or modeled utterances.
• Impaired rate/accuracy on diodochokinetic tasks (alternating movement accuracy or maximum repetition rate of same sequences such as /pa/, /pa/, /pa/ and multiple phoneme sequences such as /pa/ /ta/ /ka/)
• Disturbances of prosody including overall slow rate; timing deficit in duration of sounds and pauses between and within syllables contributing to the perception of excess and/or equal stress, “choppy” and monotone speech.
• At some point in time, groping or observable physical struggle for articulatory position may be observed (possibly not present on evaluation, but observable at some point in treatment).
• May also demonstrate impaired volitional nonspeech movements (oral apraxia).
• Verbal perseveration: getting “stuck” on a previously uttered word or bringing oral motor elements from a previous word into the next word uttered (Nancy Kaufman’s observation).

Other characteristics that may describe children with CAS, but are less likely to contribute to a differential diagnosis include:

• Poor speech intelligibility
• Delayed onset of speech
• Limited babbling as an infant
• Restricted sound inventory
• Loss of previously spoken words

Note: A speech and language pathologist must be involved to rule out other possibilities as primary reasons for the above-mentioned signs and symptoms. Simple "late talkers" can have similar characteristics.

Childhood apraxia of speech can and often does coexist with other speech and language challenges. It requires proper diagnosis and treatment by an experienced speech-language pathologist.

Apraxia of speech is usually treatable with the appropriate techniques. Children must be seen one-on-one, at least in the early stages of treatment, even as early as age 2.

Kaufman Speech to Language Protocol is a highly effective program with young children. It is currently the #1 tool used to treat childhood apraxia of speech in the US (source) and is used by speech-language pathologists in many other countries. The approach is also now being accepted and implemented into applied behavior analysis (ABA) and applied verbal behavior (AVB) programs for children on the autism spectrum.

K-SLP materials, including Kaufman Speech Praxis Test for Children, Kaufman Speech to Language Treatment Kits, Kaufman Speech to Language Workout Book, and K&K Sign/Select to Talk, are helpful tools to diagnose apraxia, determine treatment goals, and provide effective therapy.

It is imperative that children with childhood apraxia of speech gain as much practice as possible, and that is not limited to official speech session. Involvement from parents and caregivers in the child's natural environment (home, school, community) is essential for the practice needed.

With quality therapy specific to childhood apraxia of speech and support from their community, many children can make progress becoming successful vocal communicators!